1. HF
Get With The Guidelines
Heart Failure Program
Tiffany D. McGhee RN, MS, MPH
Director of Quality Improvement
American Heart Association

2. HF
Background on Heart Failure
Population Hospital 1
Group Prevalence Incidence Mortality Discharges Cost
Total $34.8
5,300,000 660,000 284,965 1,084,000
population billion
• Heart failure (HF) is a major public health problem
resulting in substantial morbidity and mortality
• Despite recent advances a substantial number of
patients are not receiving optimal care
1American Heart Association. 2008 Heart and Stroke Statistical Update.
Dallas, TX: American Heart Association; 2008.
2Hunt SA et al. ACC/AHA guidelines for the evaluation and management of
chronic heart failure in the adult. 2001.

3. HF
10
Prevalence of HF Increases With Age
Males
8
Population (%)
Females
6
4
2
0
20–24 25–34 35–44 45–54 55–64 65–74 75+
Age (yr)
US, 1988–1994
AHA. Heart Disease and Stroke Statistics
2004 Update

4. HF
Heart Failure Hospitalizations
The number of heart failure hospitalizations is increasing in both men and women
CDC/NCHS: Hospital discharges include patients both living and dead.
AHA, 1998 Heart and Statistical Update
NCHS, National Center for Health Statistics
AHA Heart and Stroke Statistical Update 2004

5. HF
New Goal
By 2020 improve the cardiovascular health
of all Americans by 20% while reducing
deaths from cardiovascular disease and
stroke by 20%.

6. HF
Bridge the Gap

7. HF
Bridging the Gap Between Knowledge and Routine Clinical Practice
AHA/ACC Clinical
Guidelines Systems
Practice
I IIa IIb III
• Implement evidence-
based care
• Improve communications
• Clinical trial evidence
• Ensure compliance • Improve quality of care
• National guidelines
• Improve outcomes
Adapted from the American Heart Association. Get With The Guidelines; 2001.

8. HF
Definition of Quality
“Degree to which health care services
increase the likelihood of desired health
outcomes and are consistent with current
professional knowledge”
– Are you doing the right things?
– Are your patients better off for it?

9. HF
Building a Continuum of Care in the Inpatient Setting
Create
culture
and
Pilot resources
Improved
Assess new QI to
Patient
Quality programs ensure
Outcomes
& greater
initiatives guideline
adherence

10. HF
Heart Failure Quality Improvement Program
• Why have a QI program for HF?
– Mortality from HF is high.
– Major reason for readmission in the US.
– Large cost to US healthcare economy.
– Improved quality of life for HF patients and
caregivers.
– Hospital benefits by open bed space.

11. HF
Why a Hospital-Based System
• Patients for HF Management?
– Patient capture point
– Have patient’s/family’s attention:
―teachable moment‖
– Predictor of care in community
• Hospital structure
– Standardized processes/protocols/
orders/teams
– Accrediting bodies for standards of care
– Centers for Medicare and Medicaid
Services—peer review organizations
• JCAHO (in-hospital)
• HEDIS (post-discharge)
Fonarow GC et al. Am Heart J. 2004;148:43–51.

12. HF
Hospital-based System in Heart Failure Reduces Readmissions
P<.0001 and Mortality Pre-intervention (n=11,038)
95* Post-intervention (n=8045)
Treatment Rates (%)
HR 0.80
65 P<.0001
46 HR 0.77
38* P<.0001
23
18*
ACEI Rx Readmissions 1-Year Mortality
Intermountain Health Care: 10 hospitals 1/1996–12/1998 (n=11,038) to 1/1999–3/2000 (n=8045)
Pearson RR et al. Circulation. 2001;104:II-838.

13. HF
Since 2001
Over 1500 Hospitals
Nationwide
Over 2 Million Patient
Records
Over 625 Hospitals
Receiving Recognition
Almost 55 Peer Reviewed
CONFIDENTIAL – American Heart Association 2009
Publications

14. HF
CONFIDENTIAL – American

15. HF
What is GWTG-HF?
• The American Heart Association’s in-
hospital quality improvement program
aimed at ensuring every heart failure
patient receives the best care possible.

16. HF
GWTG-HF Program Objectives
• Improve medical care and education of patients
hospitalized with heart failure
• Accelerate initiation of the HF evidence-based,
guideline-recommended therapies by starting these
therapies before hospital discharge in appropriate
patients
• Increase understanding of and overcome barriers to
uptake of evidence-based therapies in this patient
population

17. HF
Get With The Guidelines:
Elements of Success for Hospitals
• Attend a GWTG workshop
• Designate a champion from hospital
• Recruit care team for implementation
• Enter baseline data into the Patient Management Tool
• Institute care paths, standing orders and discharge protocols
that are consistent with the ASA/AHA guidelines
• Utilize the Patient Management Tool to record and improve
patient care.
• Achieve Performance Award levels

18. HF
GWTG Heart Failure Performance Measures
Evidence Based Recommendations
• Discharge instructions and HF patient education.
• Measurement of left ventricular (LV) function in all
eligible patients.
• ACE inhibitor or ARB provided at discharge in eligible
patients with LVEF of <40%, in the absence of
documented contraindications or intolerance.
• Beta-blocker provided to eligible patients at discharge
with LVEF <40% in the absence of documented
contrindications or intolerance.
• Smoking cessation counseling provided to all eligible
patients (current or recent smokers).
ACC/AHA Clinical Performance measures for Adults
with Chronic Heart Failure, Bonow, RO, et al.
Circulation September 20, 2005

19. HF
GWTG-HF Data Collection
• Relevant medical history • Discharge Status
• Smoking within the last 12 • If patient expired, primary cause
months of death
• HF History • Symptoms (closest to
• Symptoms (closest to discharge)
admission) • Vital Signs (closest to
• Vital Signs discharge)
• Exam (closest to admission) • Exam (closest to discharge)
• Labs (closest to admission; • Labs (closest to discharge)
peak to troponin) • Discharge medications
• Admission medications (taken • Smoking cessation counseling
prior to admission) • Discharge instructions
• Parenteral therapies • Date of discharge
• Procedures during this hospital • Process of care improvement
stay
• Ejection Fraction

20. HF
GWTG-HF
PMT Form

21. HF
GWTG-HF PMT Special
Features: Referral Note

22. HF
GWTG-HF PMT
Special Features:
Patient Ed

23. HF
GWTG-HF PMT
Reporting Interface

24. HF
Get With The Guidelines
Works!
Hospitals Participating in GWTG Provide
Higher Quality Care with Better Clinical
Outcomes than Other Hospitals

25. HF
GWTG Gets Results:Performance - Heart Failure
100%
80%
60%
40%
20%
0%
ACE or ARB at Smoking cessation Beta blockers at
Discharge LV function Composite quality of
discharge for counseling, current discharge for
instructions measurement care measure
patients w ith LVSD, smokers patients w ith LVSD,
Baseline 69.60% 90.60% 83.30% 74.30% 86.50% 80.00%
GWTG 79.40% 94.20% 85.90% 91.40% 89.40% 87.80%

26. HF
Year All HF Patients
2003 6.02 (14252)
2004 5.79 (23533)
2005 5.72 (46928)
2006 5.62 (60147)
2007 5.62 (72268)
2008 5.6 (82769)
2009 5.57 (88706)

27. HF
Year All HF Patients
2003 3.6% (547)
2004 3.7% (915)
2005 3.4% (1652)
2006 3.1% (1954)
2007 3% (2268)
2008 2.6% (2266)
2009 1.2% (1161)

28. HF

29. HF

30. HF
AHA Get With The Guidelines is
Award Winning
• First hospital-based program to receive the
prestigious Innovation in Prevention Award from
U.S. Department of Health and Human Services.
• Recipient of Inaugural eHealth Initiative (eHI) Award
Honoring Leadership in Health Care Quality through
Health IT for Transforming Care Delivery

31. HF
GWTG-HF Recognition Program Performance Measures
1. HF Discharge instructions provided to all eligible patients
2. Measurement of LV function in all eligible patients
3. ACE inhibitor and/or ARB at discharge provided to eligible
patients with LVEF < 0.40, in absence of documented
contraindications or intolerance
4. Beta blocker at discharge provided to eligible patients with
LVEF < 0.40, in absence of documented
contraindications or intolerance
5. Smoking cessation counseling provided to all eligible
patients (current or recent smokers)

32. HF
Silver Performance Achievement
Award Criteria
Indicate compliance
of applicable
performance criteria
in at least 85% of
patients for 12
consecutive
months

33. HF
Silver Plus Performance
Achievement Award Criteria
Indicate compliance of
applicable performance
criteria in at least 85%
of patients for 12
consecutive months
and at least 12
consecutive months
of 75% or higher
compliance with 4 of 9
Get With The
Guidelines Heart
Failure Quality
measures

34. HF
Gold Performance Achievement
Award Criteria
Indicate compliance of
applicable
performance criteria in
at least 85% of
patients for two
consecutive 12
month intervals

35. HF
Gold Plus Performance
Achievement Award Criteria
Indicate compliance of
applicable performance
criteria in at least 85% of
patients for consecutive
12 month intervals and
at least 12 consecutive
months of 75% or
higher compliance
with 4 of 9 Get With
The Guidelines Heart
Failure Quality
measures

36. HF
CONFIDENTIAL – American Heart Association 2009

37. HF
Challenges to Implement a Heart Failure Performance
Improvement System
• This will not work in a community practice or hospital
• The cardiologists will not agree to this
• We can not get a consensus
• The managed care organization will not pay for it
• Patients do not want to be on a lot of medications
• There is not enough time
• It will cost too much
• It may not be safe to start BB medications in heart failure patients
• This will benefit the competition
• The administration will not pay for it
• What about the liability?
• It will take too much time
• All my patients are too complex for this
• The patients should all be followed by someone else
• It is too hard to get things through the practice committee
• The physicians at my office do not like cookbook medicine
• We do not have anyone to do this

38. HF
Tools for Smooth HF Transitions
• Should target both patient and providers
• Improving transitional care
– Better communication for transferring MD
• Discharge summaries, EMR exchanges, etc
– Closer follow-up care for those who need it
• Minimizing “Door to clinic times”
– Better patient education tools
• Informing patients, family about disease, treatment
– Tools to increase medication adherence
• Pill boxes, pharmacist programs, disease management
– Disease and risk management programs
• Patient empowering, self management, multidisciplinary HF
clinics, web based programs

39. HF
Continuity of HF Care
Reliable Care: Not Missing the Steps
Hospital CCU DC Early Post Outpatient
ED Telemetry DC
• Oral •On right meds?
•Diagnosis • IV Meds Meds • Right •On right dose?
• Admit •Oral Meds • Other meds? •Volume status
• CCU? •LV function Rx? •Titration •Re-assess EF
•Acute Rx • Echo and/or •Other •Pt •Device?
•Evaluation Cath? eval Education •Self Manage?
•Other •Pt Ed Disease •Other Issues?
Evaluation •F/U Manage
•Tx to Floor •Disease •Continuity
Manage Device?
Fonarow GC Rev Cardiovasc Med.
2006;7:S3-11

40. GWTG-HF True Value HF
Actual Cost Market Value
GWTG-HF Patient Management Tool $1,195.00/year $10,000-$30,000/year
Educational Programs $40 per person $10/hour/person
-GWTG Workshop CEU/CME
Teleconferences Free Free
Patient Education Material Free $5,000-$10,000/year
QI Consultative Services Free $250-$700/hour
JC Advanced HF Certification Site Review *$500-$800 $5,000-$15,000
Technical Support Free $20-$50 charge per call
Marketing Opportunities with AHA Free $20,000-$50,000/year
Total $1,735-$2035/year $64,000-$154,000/year
*Note: For HF Certification preparatory reviews we are including a stipend to cover costs for lodging, mileage and/or air fare, and meals for AHA staff.

41. HF
GWTG-HF Cycle of Quality Improvement
Find and Support a Champion
Assess HF Treatment
Rates
Measure current treatment rates
and process-of-care indicators
Implement Refined
Protocols Evaluate Assessment
Hospital team coordinates Hospital team reviews
implementation of refined summary reports and current
protocols protocols
Refine Protocols
Hospital team
identifies
areas for
improvement

42. HF
What’s Next With
Get With The Guidelines®?

43. HF
Taking The Failure Out of Heart Failure
Collection of content-rich resources for patients
and professionals
• Educational Tools
• Prevention Programs
• Treatment Guidelines
• Quality Initiatives and Outcome-based programs

44. HF
GWTG BEST PRACTICE TOOLKIT
The best practice project demonstrates the American Heart Association’s
continued commitment in providing the GWTG community the resources
necessary to achieve quality goals.
• Purpose of the project was to determine the best practices that could be
instrumental in assisting other organizations in meeting and sustaining their
quality goals.
• Interviews, on line discussion sessions and focus groups were conducted with
over 100 professionals representing GWTG silver and gold award winning
hospitals.
• A Best Practice multimedia on-line guidebook will be the result of this in depth
market research.
• The guidebook will initially contain 15 -17 best practices for HF and Stroke.
Each best practice process is described in detail including supporting
documents and educational programs.
• Organizations will be able to adapt these best practices and tools to assist in
meeting quality goals.
CONFIDENTIAL – American Heart Association 2009

45. HF
TJC Advance Certification in HF

46. HF
HF

47. HF
―Knowing is not enough;
we must apply.
Willing is not enough;
we must do.‖
Johann von Goethe

48. HF